CASE # 6

Questions

1. What is the rationale of drying the newborn thoroughly?

Heat is lost per second due to evaporation, conduction, convection, and radiation when exposed to the
outside environment. This risk is reduced by thorough drying, rapid skin-to-skin contact after delivery,
and covering with a blanket and bonnet (prior to cord clamping). The newborn's body temperature can
drop rapidly after birth causing potentially life-threatening neonatal hypothermia, the risk of which can
be reduced by drying the newborn immediately. Breathing is also stimulated by drying. Sustained skin-
to-skin contact also aids olfactory learning, effective colostrum intake, and long-term breastfeeding by
colonizing the newborn with maternal flora (rather than hospital flora).

2. Should the vernix caseosa be wiped off after the delivery? Why?

If not wiped away after birth, Vernix caseosa is a white, cheesy protective coating of
desquamated epithelial cells and sebum that is found in newborns and aids extra-uterine adaption of
skin in the first postnatal week. Apart from providing protection, it also acts as a thermoregulator,
keeping the baby warm. To facilitate instant mother and newborn bonding, this should not be wiped off
right after delivery. To maintain the vernix for a little longer during skin-to-skin contact in the initial few
hours after birth, as well as to offer extra warmth for the infant to prevent distress and difficulties, it is
usual practice nowadays to delay the first bath. The World Health Organization (WHO) recommends
waiting at least 6 hours before bathing the newborn baby and ideally waiting about 24 hours. The WHO
also recommends not wiping off the vernix at birth.

3. When is the ideal time to clamp and cut the cord? Why?

Early cord clamping occurs within the first 60 seconds of birth, whereas late cord clamping
occurs more than one minute following birth or when cord pulsation has stopped. The cutting of the
cord is part of the stimulus that causes the child to take his or her first breath or represents the most
critical shift into the outer world for the newborn, the creation of independent respirations. For a few
minutes after birth, the umbilical cord continues to pulsate, then stops. When the chord is not cut until
pulsation stops and the newborn is kept at a uterine level, up to 100ml more blood can transfer from
the placenta into the fetus than if the infant is held in a superior posture or the cord is cut right away. As
a result, postponing cutting helps to ensure that the newborn's red blood cell and white cell counts are
acceptable.

4. Discuss the significance of performing APGAR Scoring. Is 9/10 APGAR Score normal? Why?

The Apgar score, when properly administered, reflects the newborn infant's state shortly after
birth and can be used for standardized testing. It also allows for the fetal-to-neonatal transition to be
recorded. Apgar ratings do not predict individual mortality or a poor neurologic outcome. The better the
baby's post-natal outcome, the higher the score. A score of 7, 8, or 9 is deemed normal and indicates
that the baby is in good health. A ten-point score is highly uncommon, as almost every newborn loses
one point owing to blue hands and feet, which is usual after birth. Very few babies get a perfect Apgar
score – in fact at our hospital, fewer than 1 in 100 get that perfect 10. A score of 7 to 10 is considered
normal for both the one-minute and five-minute Apgar tests. A score in this range usually means that
your babies in good shape and doesn't need more than routine post-delivery care.

5. What are the 5 signs to be assessed in APGAR Scoring?

The 5 signs to be assessed in APGAR scoring are:

1) Heart Rate

2) Respiration

3) Muscle Tone

4) Reflexes

5) Color

Parameter 0 1 2

HEART RATE Absent Slow less than 100 Greater than 100
RESPIRATION Slow Slow, irregular, weak cry Good, strong cry
MUSCLE TONE Flaccid Some flexion Well flexed
(ACTIVITY)
REFLEX IRRITABILITY No response Grimace Coughs and sneezes
(GRIMACE)
COLOR Blue, pale Body – pinkish in color Pinkish in color
Extremities - pale

The Apgar score is a quick way to assess a baby's cardiorespiratory adaption after birth. The
nurse gives the infant a score in each of the five areas after 1 minute and 5 minutes. The evaluations are
ranked from most important (heart rate) to least important (blood pressure) (color). In each of the five
areas, the infant is given a score ranging from 0 to 2, and the scores are added together. It is not
necessary to delay resuscitation until the 1-minute score has been reached. The infant's care is based on
three 1-minute score ranges: 0 to 2, 3 to 6, 7 to 10, and 10 to 12.

6. What is the importance of Crede’s prophylaxis? How should the medication be administered?

In the late 1800s, Credé's prophylaxis was a huge stride forward in the prevention of
inflammatory eye disease in neonates. Credé procedure is the practice of washing a newborn's eyes
with a 2% silver nitrate solution to protect against neonatal conjunctivitis caused by Neisseria
gonorrhoeae. Inflammatory eye disease in infants can be prevented by Credé's prophylaxis. This drug is
given to the newborn by infusing a generous amount of the opthalmic ointment prescribed by the
doctor in the lower conjunctival sac of the baby's eye, commencing from the inner to the outer canthus.
To avoid harm, the tube's tip should not come into contact with the eye or eyelid. Credé's method of
instilling a drop of 2% aqueous solution of silver nitrate into a newborn's eyes was first published in
1881 and significantly advanced the prevention of neonatal conjunctivitis. Silver nitrate is a surface-
active chemical that facilitates agglutination and inactivation of gonococci.

7. What is the importance of Vit. K injection? Give the dosage, route and site of administration?

Neonates are administered vitamin K because they cannot produce it in the intestines without
the presence of bacterial flora. They are at risk for infant hemorrhagic illness as a result of this. After
delivery, a single intramuscular dosage of vitamin K prevents bleeding until the newborn is able to make
enough vitamin K on his or her own. For prophylaxis, doses of 0.5 to 1 mg (0.25 to 0.5 mL of solution
containing 1 mg/0.5 mL) are administered intramuscularly once within 1 hour of delivery. Vitamin K is
used to treat and prevent low levels of specific molecules produced by your body (blood clotting
factors). It's given as a preventative measure to avoid a brief lack of coagulation factors II, VII, IX, and X.
These compounds aid in the normal thickening and stopping of your blood (e.g., after an accidental cut
or injury). It aids in the prevention and treatment of hemorrhagic conditions in newborns. Antidote for
oral anticoagulant-induced bleeding and hypoprothrombinemic conditions caused by vitamin K
insufficiency.

8. Why is Hepa vaccine given? Give the dosage, route and site of administration.

The Hepatitis Vaccine is given to babies to protect them from contracting hepatitis. Newborns
born to mothers who have acute or chronic hepatitis B infection (hepatitis B surface antigen [HBsAg]
positive) are at risk of contracting the virus. Infected newborns have a significant risk of having a
persistent infection that can lead to cancer or other serious liver disease later in life. Both the vaccine
and hepatitis B immune globulin should be given to these infants (HBIG). HBIG is a hepatitis vaccine that
provides passive immunity to infants until they acquire their own antibodies. It should be given within
12 hours of birth. The vaccine encourages the production of antibodies, which protects newborns from
subsequent disease exposure. Hepatitis B vaccine is also given to uninfected moms' newborns. It is
administered intramuscularly in the upper section of the thigh, Vastus Lateralis, at a dose of 0.5 mL.

9. What is the significance of Newborn Screening? How it is being done?

Newborn screening allows doctors to detect and treat certain diseases before they cause a
newborn to become ill. Most newborns with these disorders who are diagnosed and treated early
enough are able to grow up healthy and develop normally. Newborn screening helps us find babies who
have certain serious medical conditions so that they can begin treatment right away. In most cases,
these babies look normal and healthy at birth. They usually do not begin showing symptoms until a few
weeks or months later. Newborn Screening (NBS) is a straightforward process that determines if the
infant has a congenital metabolic disease that, if left untreated, might result in mental retardation or
even death. The best time to screen a newborn is within the first 24 hours after birth. Blood is drawn
from the baby's heel and wiped on a specific absorbent filter card before being delivered to the
Newborn Screening Center (NSC).

10. Based on the scenario, are the results of anthropometric measurements normal? Explain briefly.

Anthropometric measurements such as length, weight, and head circumference are routinely
used to determine an infant's growth and development. Individual measures are usually compared to
reference standards, which are represented by percentile curves on a growth chart. Neonatal
anthropometric measurements are an important clinical technique for identifying neonates that are
abnormally tiny or large. Measurements offer data on the infant's development.

The following are the result based on the case scenario and the normal measurements:

Result Normal Values

Head Circumference 34 cm 34-35 cm. (The head should be
bigger than the chest about
2cm.)
Chest Circumference 32 cm 32-33 cm
Abdominal Circumference 30 cm 33.23
Length 47 cm 46-54 cm
Weight 3,200 grams 2500 grams – 3400 grams

11. Differentiate between physiologic and pathologic jaundice. Give the management for each.

Physiologic jaundice in newborns is characterized by a yellowish staining of the skin and whites
of the newborn's eyes (sclerae) caused by bile pigment (bilirubin). A degree of jaundice is usual in
newborn newborns. On the other hand, pathologic jaundice is the most dangerous type of jaundice. It is
characterized by a fast spike in a baby's bilirubin level within 24 hours of birth. Blood incompatibility or
liver illness are the most likely causes. Medical assistance must be sought immediately, and blood
transfusions may be required. Phototherapy and/or exchange transfusions of donor blood are used to
treat jaundice if bilirubin levels require it. The underlying cause of pathological jaundice must also be
addressed. The importance of parental engagement in reducing the trauma of having a sick baby and its
impact on bonding is critical. In cases of pathological jaundice, the underlying cause must also be
treated. Parental involvement is important to minimize the trauma of having a sick baby and its effect
on bonding.

12. Formulate your Nursing Care Plan and Drug Study.

Name of Drug Dosage, Mechanism Indication Adverse Special Nursing
Route, of Reaction Precaution Responsibilities
Frequency Action
and
timing
Generic: Dosage: Active Indicated for Pain or -The tip caps Be aware of maternal
Hepatitis B vaccine immunization immunization soreness at of the prefilled hepatitis status at
with hepatitis B against infection the injection syringes appropriate ages.
vaccine caused by all site Fatigue contain natural
stimulates the known subtypes of rubber latex Notify physician of
Route: immune system hepatitis B virus; which may need for vaccine.
Intramuscular to produce anti- Immunoprophylaxi cause allergic
Subcutaneous HBs without s against Hepatitis reactions.
(for patients at exposing the B -Syncope Draw back on the
risk for patient to the (fainting)can plunger of the
Brand: hemorrhage) risks of active occur in syringe before
Energix B, infection. association injection to avoid
Recombivax Infection with with intravascular
HB hepatitis D can administration injection.
occur only with of injectable
Frequency: concurrent vaccines, Assess client for the
hepatitis B including following:
infection, so ENGERIX-B.
vaccination with Procedures
-Soreness or redness
recombinant should be in
at injection site
hepatitis B place to avoid
vaccine falling injury
provides and to restore
Timing: protection cerebral -Fever
against hepatitis perfusion
D as well. The following
recombinant syncope. -Fatigue
hepatitis B -Temporarily
vaccine is defer
produced by vaccination of
injecting infants with a -Appearance of
Saccharomyces birth rashes
cerevisiae weightless
(yeast) with a than 2,000 g
plasmid that born to -Difficulty of
codes for the hepatitis B Breathing
adw subtype of surface
HBsAg. The
antigen
genetically -Cold symptoms
(HBsAg)-
altered yeast
negative
produces
mothers.
significant
-Apnea -Low blood pressure
quantities of
following
HBsAg, which
intramuscular
are released by
vaccination
cell disruption, -Flushing
has been
collected, and
observed in
purified. The
some infants
particulate
born -Muscle, joint, and
matter present
prematurely. back pain
in the hepatitis
Decisions
B vaccine,
about when to
recombinant
administer an -Seizures
contains large
intramuscular
amounts of
vaccine,
protein derived
including
from HBsAg -Irritability
ENGERIX-B,
against which
to infants born
an immune
prematurely
response occurs,
should be -Diarrhea
resulting in the
based on
formation of
consideration
 anti-HBs. of the infant’s
Extensive study medical status, -Reduced Appetite
of the and the
recombinant- potential
stimulated benefits and
antibodies possible risks
reveals that they of vaccination.
are remarkably
similar to
naturally
occurring anti-
HBs in variety,
biochemistry,
potency, and
protective
efficacy.
Classification Contraindications Side Effects
Functional: *Anaphylactic Side effects
Viral Vaccine reaction to previous are usually
hepatitis B vaccine mild and go
dose away in a
few days.
*Moderate or They may
severe acute illness include: -
Chemical: *Soreness or
Subunit/ redness
conjugatevaccin where the
shot was
given
*Fever
*Irritability
*Diarrhea
*Reduced
appetite

-Cold
symptoms
-Low blood
pressure
-Flushing
-Back and
muscle pain
-Seizures

Serious side
effects from
the hepatitis
B vaccine
are very
rare.
 Dosage, Route,
Mechanisms of Special Nursing
Name of Drug Frequency and Indication Adverse Reactions
Action Precautions Responsibilities
Timing
Generic: Dosage: -Monitor PT,
phytonadione 0.5 ml Promotes hepatic Prevention, treatment Newborns (esp. international
formation of of hemorrhagic premature infants) normalized ratio (INR)
coagulation states in neonates. may develop routinely in those
Route: factors II, VII, IX, Antidote for hyperbilirubinemia taking anticoagulants.
IM X. Essential for hemorrhage . Severe reaction -Assess skin for
Brand: normal clotting of (cramp-like pain, ecchymoses, petechiae.
Vit. K induced by oral
blood. Readily anticoagulants, chest pain, -Assess gums for
absorbed from GI hypoprothrombine dyspnea, gingival bleeding,
tract (duodenum) mic states due to facial flushing, Erythema.
after IM, vitamin K deficiency. dizziness, -Assess urine for
subcutaneous Hypoprothrombinemia rapid/weak pulse, hematuria.
Frequency:
administration. caused by rash, diaphoresis, -Assess Hct, platelet
Metabolized in malabsorption or hypotension count, urine/stool
liver. Excreted in inability to progressing culture
urine; eliminated synthesize vitamin K. to shock, cardiac for occult blood.
by biliary system. arrest) occurs -Assess for decrease
Onset rarely, in B/P, increase in
Timing: of action immediately after pulse rate, complaint of
(increased IV administration. abdominal/back pain,
coagulation factors severe headache (may
be evidence of
hemorrhage).
-Assess for increase in
amount of discharge
during menses.
-Assess peripheral
pulses.
-Check for excessive
bleeding from minor
cuts, scratches
Classification Contraindications Side Effects
Functional:
antihemorrhagic Pain, soreness,
None known.
swelling at IM
Cautions:
injection site,
Renal impairment,
pruritic erythema
newborns (esp.
(with
premature):
Chemical: repeated
Risk of hemolysis,
Fat-soluble injections), facial
jaundice,
vitamin. flushing, altered
hyperbilirubinemia
taste.
 Dosage, Route,
Mechanisms of Adverse Special Nursing
Name of Drug Frequency and Indication
Action Reactions Precautions Responsibilities
Timing
Generic: Dosage: instill 4- Readily Superficial Allergic Overgrowth of -Wash your
6 times daily absorbed. ocular infections reactions non-susceptible hands before
Oxytetracycline Protein binding: organisms administering the
HCl 5 mg 30%–60%. ointment
polymyxin B Widely
sulfate distributed.
Route: Excreted in
Brand: urine; eliminated
Terramycin in feces through
Opthalmic biliary system
Ointment
Frequency:

Timing:
Classification Contraindication Side Effects
s
Functional:
Prevents the
growth of
microorganisms

Chemical:
Anti-Infective